Neonatal Review and Update

In July last year we took the decision to change admission arrangements for neonatal facilities. The unit stopped providing intensive care. Any women expected to deliver earlier than 32 weeks were transferred to a neighbouring facility. This step was taken because we wanted to better understand why there had been a greater number of deaths than we would normally expect on our neonatal unit between January 2015 and July 2016.

In addition we requested a review of the unit from The Royal College of Paediatrics and Child Health and the Royal College of Nursing. The Trust received the final copy in December 2016. We asked for this external assessment, it was not imposed on us or mandated.

In the report, there is no single cause or factor identified to explain the increase we have seen in our mortality numbers. The review makes a total of 24 recommendations across a range of areas including compliance with standards, staffing, competencies, leadership, team working and culture. We are already working to implement these recommendations.

One of the recommendations included conducting a further thorough independent review of each neonatal death between January 2015 and 2016 to determine any factors which could have changed the outcomes. While this has now been completed as a matter of priority, it has led to the review taking longer than originally anticipated.

The change to admission arrangements will remain in place until we are certain we have acted on all the recommendations in the review.

Medical Director at The Countess of Chester Ian Harvey said: “We’ve acted swiftly to get the 13 individual external case note reviews completed as advised by the Royal College. This has been a detailed exercise, concluded within the last two weeks. This means that when we speak with parents we can now share full and accurate information, on an individual basis. We are desperately sorry for any distress or upset this review has caused. We know those families affected have been through so much already.”

Chief Executive Tony Chambers said: “Throughout this we have never lost sight of the families left bereaved by the loss of their baby, and they have always been our primary concern. It must have been devastating for them to lose their baby, and then face a period of not knowing. We are now able to share everything that we understand about what has happened here and our thoughts are with them.”